Trends in the Treatment of Rheumatoid Arthritis in Latin America презентация

Hospital Universitario Mayor
Bogota, Colombia



www.urosario.edu.co/crea

Trends in the Treatment of Rheumatoid Arthritis in Latin America

Latin America & the Caribbean (LAC) are like and what we can learn about rheumatoid arthritis from LAC.
Treatment of rheumatoid arthritis in LAC.

where Romance languages (i.e., those derived from Latin) – particularly Spanish, Portuguese, and French – are primarily spoken.

Area: 21,069,501 km² (7,880,000 sq mi), almost 3.9% of the Earth's surface or 14.1% of its land surface area.

Population: ~ 600 million and an economic growth rate of ~4%.

expected among some Amerindian groups (Tlingit, Yakima, Pima, and Chippewa Indians).
Del Puente A, et al. Am J Epidemiol. 1989;129:1170-8.
Ferucci ED, et al. Semin Arthritis Rheum. 2005;34:662-7.

Compared to Caucasians, RA in Latin America has an earlier age at onset and affects more women than men (5.2:1) with some clinical characteristics that differ from RA presentation in men.
Barragán-Martínez C, et al. Gend Med 2012; 9:490-510.

Loci associated with Amerindian ancestry in Latin American patients with RA were found in the “Genómica de artritis reumatoide” (GENAR) project
López Herráez D, et al. Arthritis Rheum 2013;65:1457-67.

diseases is not random

Anaya JM. Autoimmun Rev 2014;13:423-6.
Cárdenas-Roldán J, et al. BMC Med 2013;11:73.
Anaya JM. Arthritis Res Ther 2010;12:147.
Anaya JM, et al. Expert Rev Clin Immunol 2007;3:623-35

cohort (N =1,177)

Alarcón-Segovia D, et al. Arthritis Rheum 2005;52:1138-47.

High familial aggregation of RA in Latin American families with SLE (λs: 3.3, λp: 5.3).

A higher percentage of Mestizo SLE patients had relatives with autoimmune disease (54.9%) compared with non-Mestizo patients (41.1%) (p=0.001).

Rev. 2010;9:229-32.

et al. Submitted

Anaya. Autoimmun Rev 2007;6:402.

factor for Rheumatoid Arthritis
in Latin Americans

Risk Factor for Rheumatoid Arthritis
in Latin Americans

Colombians

Anaya JM, Gomez LM, et al. Genes Immun. 2005;6:628-31.
Ramirez et al. Exp Rheumatol 2012;30:520-4.

et al. Genes Immun. 2005;6:628.
Ramírez et al. Clin Exp Rheumatol 2012
Argentinians
Orrú et al. Hum Mol Genet 2009;18:569.

PTPN22 (1858 T) is a Pleiotropic Autoimmune Allele
in Latin Americans

Sjögren´s Syndrome
Colombians
Anaya et al. Genes Immun. 2005;6:628.

Type 1 Diabetes
Colombians
Anaya et al. Genes Immun. 2005;6:628-31.
Brazilians
Chagastelles et al .Tissue Antigens 2010;76:144.
Rassi et al. Ann N Y Acad Sci. 2008;1150:282.

RA (< 12 months) is of a summit importance because early diagnosis exerts beneficial effects on radiological and functional prognosis compared to later diagnosis.

The 2010 ACR/EULAR criteria identify more patients with early RA than does the 1987 ACR criteria. However, the rate of false-positive cases is higher with the newer criteria.

For established RA discriminatory powers of the 2010 ACR/EULAR and the 1987 ACR criteria are similar.

Smoking increases the disease activity of RA and reduces clinical and functional responses over time. However, there is no sufficient evidence regarding its influence on radiological disease progression.

Mota LM, et al. Rev Bras Reumatol 2013;53:141-57.

measurement is related to prognosis (i.e., radiological progression and mortality).
The sensitivity of anti-CCP is similar to that of RF, but its specificity is higher, particularly in the early disease stages.
Anti-CCP evaluation is recommended in patients with a clinical suspicion of RA and negative for RF.
RA progression is more severe in patients with extra-articular manifestations.
Conventional radiography must be used in diagnostic and prognostic assessments. When needed and available, US and MRI should also be used.

Mota LM, et al. Rev Bras Reumatol 2013;53:141-57.

polymorphism is associated with RA. Although it is not predictive of specific therapeutic responses to biological therapy, it is predictive of remission when associated with anti-CCP. Alone or in combination with HLA- DRB1 (SE), the PTPN22 polymorphism allows estimations of radiological progression.

The HLA-DRB1 gene seems to play a more important role in the prediction of poor prognosis relative to the progression, activity, severity, and mortality of RA.

Mota LM, et al. Rev Bras Reumatol 2013;53:141-57.

patients with early RA (1 year from the first RA symptoms), from 46 centers in 14 Latin American countries, followed for 24 months.
Female: 85%
Rheumatoid factor (+): 76%
Mean age at diagnosis: 46.5 (SD, 14.2) years,
Mean disease duration at the first visit: 5.8 (SD, 3.8) months.
Women had earlier onset than men (median 44.6 vs. 49.7 years, p<0.001)

Cardiel MH, et al. J Clin Rheumatol 2012;18:327-35.
Massardo L, et al. J Clin Rheumatol 2009;15:203-10.
Soriano ER, et al. Rheumatology (Oxford). 2008;47:1097-9.
Cardiel MH, et al. Rheumatology (Oxford) 2006;45 Suppl 2:ii7-ii22.
Pons-Estel BA et al. Ann Rheum Dis 2008;67(Suppl II):336

Rheumatoid Arthritis in Latin America

in 10%, and erosive disease is observed in 27.5% of patients. Joint erosions are observed more frequently in RF-positive patients and in those with no, or partial medical insurance coverage.
Pons-Estel BA et al. Ann Rheum Dis 2008;67(Suppl II):336

Low/low-middle socioeconomic status influences disease activity in early RA.
Massardo L, et al. Arthritis Care Res (Hoboken). 2012;64:1135-43.

Patients have a low understanding of their disease.
Werner AM, et al. Rev Méd Chile 2006; 134: 1500-6
Cadena J & Anaya JM. Arthritis Rheum 2003;49:738-40.
  

Patients
with Rheumatoid Arthritis

Latin America & the Caribbean (LAC) are like and what we can learn about rheumatoid arthritis from LAC.
Treatment of rheumatoid arthritis in LAC.

32.1%
Sulfasalazine: 7.1%
LEF: 4%.
Combination therapy as initial treatment: 26%.
MTX + Antimalarials: 70%
Biologics: 1%.
Corticosteroids: 64%

Cardiel MH, et al. J Clin Rheumatol 2012;18:327-35.

Clin 2013;9:106-12.

for beginning biological therapies, hierarchic sequence for using available biological drugs, and for suspending or switching them.

Systematic review of the literature vs. opinion of experts and consultants.

The recommendations for treatment of RA should be updated more frequently.

Fernandes et al. Rev Bras Reumatol 2011;51:220-30.

Reumatol. 2011;51:152-60
De la Vega M, et al Rev Arg Reumatol. 2013;24:08-14

al. Rev Arg Reumatol. 2013;24:18-26

Rheumatoid Arthritis

Chaparro del Moral R, et al. Rev Arg Reumatol 2013;24:18-26

Suspending Biological Therapy

of RA should be adapted to the presence of comorbidities.

Angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers are preferred to treat systemic arterial hypertension.

In patients diagnosed with RA and diabetes mellitus, the continuous use of a high cumulative dose of corticoids should be avoided.

Management of Comorbidities
in Patients with Rheumatoid Arthritis

Pereira IA, et al. Rev Bras Reumatol 2012;52:474-95.

mg/dL and the atherosclerotic index lower than 3.5 in patients with RA who have other comorbidities.

Metabolic syndrome should be treated.

Performing non-invasive tests to investigate subclinical atherosclerosis is recommended.

Greater surveillance for the early diagnosis of occult malignancy is recommended.

Preventive measures of venous thrombosis are suggested.

Pereira IA, et al. Rev Bras Reumatol 2012;52:474-95.

Management of Comorbidities
in Patients with Rheumatoid Arthritis

of 50 years and in younger patients on corticoid therapy at a dose greater than 7.5 mg for over three months.

Patients with RA and osteoporosis should be instructed to avoid falls, to increase their dietary calcium intake and sun exposure, and to exercise.

Calcium and vitamin D supplementation is suggested. Bisphosphonates are suggested for patients with T score < –2.5 on bone densitometry.

A multidisciplinary team, with the active participation of a rheumatologist, is recommended to treat comorbidities.

Pereira IA, et al. Rev Bras Reumatol 2012;52:474-95.

Management of Comorbidities
in Patients with Rheumatoid Arthritis

product confirmed by a comparability exercise and showing similar quality, safety, and efficacy.

They promote cost containment and favor the sustainability of modern health systems in a panorama of aging population, demographic transition towards chronic diseases like RA, costly health technologies, and limited resources.

Desanvicente-Celis Z, et al. Immunotherapy. 2012;4:1841-57.
Desanvicente-Celis Z, et al. Biosimilars 2013;3:1-17.

Biosimilars are available in Mexico, Brazil, Chile, Ecuador, Bolivia, Peru, Argentina, Panama, Guatemala, Costa Rica, and Colombia.

other regions in the world.

Make RA a public health priority, knowing its socioeconomic impact in terms of its high cost and burden on the health-care system.
Burgos-Vargas R, et al. Reumatol Clin 2013;9:106-12.

Building own evidence-based practice through research.

Education!

« Traiter vite et fort! »
Early Arthritis Clinics
Marcos J, et al. General characteristics of an early arthritis cohort in Argentina. Rheumatology 2011;50:110-6. 
Arbeláez-Cortés A, et al. The Cali early arthritis clinic. Biomed Res Int 2014;2014: in press.

Provide access to medications. Low cost - Price regulation.

respect have fulfilled their mission, the whole American continent will be a vast alliance of dignity and civilization brought about by languages and traditions?”

“¿Como no desear que algún día, cuando la vecindad , la colaboración y el respeto hayan cumplido su misión, todo el continente americano sea una vasta alianza de dignidad y de civilización propiciada por las lenguas y por las tradiciones?”